Case Discussion

I think this is an excellent case because of the risks involved in not treating
this in the proper fashion. Handled incorrectly, there will be serious consequences
for the patient, so the surgeon needs to know the algorithm of how to get this
patient properly treated. Once the decision is made, the treatment itself is
fairly straightforwardit's the process of carefully thinking through the
treatment decision that's the take-away from this case.

Dr. Albert handled this case correctly and demonstrates the importance of getting
an MRI on a patient like this. The current recommendation is to get an MRI before
reducing so that you know what you're dealing with. This is especially true
if the patient is incoherent and can't talk to you, but it even applies if the
patient is neurologically intact, as this patient was.

While I agree with how Dr. Albert treated the case, I would have done this
case semi-emergent. I wouldn't have waited to treat in the morning. In a young,
healthy adult like this patient, there is no benefit in waiting; he has no other
medical issues or injuries from this trauma, and he has an unstable spine.

Based on the MRI, I would not reduce this patient in the ER. I would put the
patient in traction in the OR and check his alignment using an x-ray.

I would then do an ACDF, followed by posterior stabilization, just as Dr. Albert
did. However, as mentioned before, I wouldn't wait and instead would treat immediately.

Author's Response

Surgeon in Chief and Medical DirectorKorein-Wilson Professor of Orthopaedic Surgery

Hospital for Special SurgeryWeill Cornell Medical College

I appreciate Dr. Girasole's comments. In general, we would not hesitate to
reduce a patient like this awake in the emergency room with Gardner-Wells tong
traction (sometimes employing high weights).

What is also different about this case is the findings on the CT (obtained
immediately) suggestive of bone/disc in the canal. This combined with the MRI
(obtained to clarify) forced us to urgent surgery within the next 12 hours.
If a traction reduction were to be performed, the critical issue is to have
the patient awake and alert (functioning as the best neurologic real-time monitoring).

nice case. but I would like to draw attention to Dr. Albert's remark "In general, we would not hesitate to reduce a patient like this awake in the emergency room with Gardner-Wells tong traction (sometimes employing high weights)."
In the modern setting, is it not time to move past traction and manipulative reduction in the ER? (traction alone worsens the rotation, so manipulative reduction is required. )Once reduction is accomplished in the ER, I think we are all going to do an ACDF plus or minus posterior stabilization, and not just go with a halo brace.The reduction can be carefully and safely controlled at the time of surgery.